uclasurgeryfandomcom-20200214-history
Pediatric Surgery Operations
Single Incision Appendectomy - Dr. DeUgarte Key Materials Single 5mm trocar 5mm 30 deg scope Laparoscopy kit 2-0 silk stick ties Pointed bovie tip 2-0 prolene on UR needle Operative Steps 1. Grasp umbilicus with adsons. Point 11 blade scalpel, blade up, through bellybutton and up in a hooking motion. Cut umb attachments with scalpel 2. Bovie down to umbilical ring 3. Dilate ring with hemostat 4. Using bovie tip, cut ring superiorly if needed to fit trocar 5. Insert trocar sheath with rounded metal tip parallel to abd wall, remove metal tip 6. Insert 5 mm trocar over sheath, make sure trocar is only in abd as little as possible. 7. Using 2-0 silk, suture trocar to skin. 8. Before insufflation, confirm view with scope 9. Start insufflation to 15 mm Hg 10. Inspect RLQ, liver, pelvis, etc, with scope 11. Using 11 blade, make stab incision inferior to umb ring (not contiguous with trocar) 12. Insert marilyn/platypus via stab incision, you will lose some pneumoperitoneum 2/2 leak 13. Pull back scope for best view 14. Moving scope and instrument together, visualize appendix/bluntly dissection adhesions as needed. Adhesions divided using electrocautery/blunt dissection. 15. If needed, can make separate stab incision to fit 2nd instrument near umbilicus 16. Once appendix is mobile, switch instrument handle for a locking handle, clamp on appendix 17. Keep instrument with appendix still, remove scope, trocar (& anchoring stitch), other instruments 18. Using scalpel, divide tissue between instrument and dilated umb ring to make contiguous opening 19. Slowly retract lap instrument to deliver appy into field, using hemostat/clamps, clamp appy 20. Dissect mesoappendix/adhesions with hemostat, lyse by picking up bands of tissue with pick-up then "tap-burn" by tapping bovie on pick-up, then cut with bovie. 21. Once dissection is carried to base of appendix, crush with hemostat 22. Use 2-0 silk stick tie at crushed area 23. Repeat crush/stick tie 5mm above previous tie 24. Clamp above 2nd tie, cut under with scalpel. Touch scalpel blade to cut edge and cauterize with bovie 25. Replace appy into abdomen 26. Using adsons, 2-0 prolene on UR needle, place figure of eight at umb to close fascia 27. No skin sutures to close umb, just mastisol -> steristrip -> folded 2x2 pressure dressing at umb -> tegaderm. Roll an edge of tegaderm for easy removal Laparoscopic->Open Reduction Intusseception, Small Bowel Resection - Dr. DeUgarte Key Materials Operative Steps 0. Before starting, try to feel intusseception and manually reduce while pt asleep. Imagine its "like pushing a tube of toothpaste." If you look inside and there's no intusseception, can stop. 1. Grasp umbilicus on either side with adsons until everted 2. Turn 11 blade facing up, drive scalpel through bellybutton, with a hooking up motion to cut through umb 3. Using sharp/electrocautery, divide umb stalk from ring bilaterally 4. Use tonsil to find umbilical ring, open slightly with electrocautery 5. Place 5 mm mm trocar into umbilicus, insufflate. View with 5 mm thirty degree scope. 6. Triangulate to area of intusseception to choose trocar sites 7. Using 11 blade, stab perpendicular to skin under direct vision, blade will PASS THROUGH peritoneum. ANCHOR YOURSELF w/ PINKY. 8. Using a closed mosquito, find the same defect 9. Then, insert platypus/instrument directly through same defect 10. Repeat for two trocars. Get two platypus. 11. Grasp small bowel exiting intusseception. Keep GENTLE traction with hand on small bowel (easy to rip), use other platypus to push rolled, antimesenteric lip of cecum off the small bowel a few centimeters then grasp small bowel. Move your first grasper up until it meets the 2nd. Proceed slowly without allowing the small bowel to re-intussecept. Due to difficulty, converted to open 12. Enlarged incision to 4 cm vertical midline incision, 2 cm each direction from umbilicus. 13. Small bowel was dilated and unable to visualize intusseception, mobilized small bowel out of abdomen 14. Attempted manual reduction "tube of toothpaste" method — unsuccessful 15. Removed small bowel from abdomen, felt intusseception in RUQ 16. Mobilized asc colon by dividing lateral attachments and hepatic flexure bluntly with finger 17. Brought intusseception out of wound 18. To resect, chose avascular window at mesentery, score with bovie, pop through with tonsil 19. Place GIA stapler through window, stapled terminal ileum, transverse colon 20. Staying close to bowel, divided mesentery by making a avascular window, clamping mesentery from free edge to window, dividing mesentery with cautery, tying with 2-0 silk tie. 21. To do stapled anastomosis, place 2-0 silk stay sutures to align anti-mesenteric edges (see diagram) 22. Make enterotomies in the afferent and efferent limbs, suction clean. Place contaminated instruments aside. 23. Insert long GIA into aff and eff limb, pull bowel up on stapler. Fire GIA. 24. Inspect staple line for hemostasis 25. Sew enterotomy with running 3-0 PDS suture. Bites. PDA Ligation Dr. Shew Key Materials: Operative Steps: 1. Position patient right lateral decubitus (left side up), rolled up ABDs or soft gauze at sides, abd between arms/legs 2. Mark nipple, inferior tip of scapula 3. Prep & Drape 4. Make 4 cm transverse, slightly curvilinear incision below tip of scapula with 15 blade 5. Grasp skin with adsons, divide through dermis with cautery 6. Using cautery, divide latissimus along incision, followed by serratus anterior 7. Score intercostals with cautery, bluntly dissect ribs apart with mosquito, then divide intercostal muscles to access chest 8. Insert Finechetto (small baby retractor) 9. Using malleable retractors, GENTLY retract lung back and up. May need to relase lung if desat or hypotension. 10. Incise pleura overlying aorta, PDA 11. Using mosquito, gently dissect PDA by placing tips between asc arch of aorta and PDA, away from aorta, gentle spread parallel to aorta. Using debakey, pull aorta down and away to expose this space. Be cognizant of RLN. 12. Dissect inferior to PDA 13. Place medium size titanium clip on drape first to test. Then, clip PDA 1-2 mm away from aorta. 14. Irrigate with normal saline. DO NOT suction in cavity. Suction over gauze.